Payor Summit April 2, 2010

1. Payor SummitApril 2, 2010 © South Carolina HFMA - All Rights Reserved Medicaid Update

2. Managed Care

3. Managed Care Purchase Effective June 1, 2010

4. Managed Care • Carolina Crescent members will auto-convert into Advanced Total Care • Members will have the option to move from June 1st until August 18th • Members opting to move during June will not convert until July 1, 2010 • Non-pars with Absolute will be paid as participating • No special prior authorizations for new converts (usual medical necessity continue to apply) • Patients inhouse on May 31 will complete the stay and be billed as Carolina Crescent members • Guaranteed continuity. Contact Roy Hess directly with problems

5. Managed Care June 1, 2010 Absolute Total Care 19%

6. Managed Care June 1, 2010 Absolute Total Care 39%

7. Managed Care Total Managed Care/MHN 68% Total FFS 32%

8. Managed Care December 19, 2008 DSH Audit Rule • Settled to cost in DSH UPL

9. Managed Care Reminders: Out-of-network proviso • No longer requires MCOs to pay fee schedule on out-of-network claims (“swung both ways”) • Can contract for independent services outside of traditional managed care contracts

10. Fee For Service • Current rates imitated October 1, 2009 • October 1, 2010 based on FY 2009 RCCs using October 2009 to June 2010 paid claims data • Separate Lab fee schedule begins October 1, 2010 • Will result in changes to current fee schedule and multipliers

11. Staff Education SCDHHS Website http://www.scdhhs.gov/whatsnew.asp

12. DSHfunctional

13. DSHfunctional • 12-19-08 DSH Audit Rule • Due from Clifton Gunderson January 31, 2010, still not completed • 2007 still due from CG September 30, 2010 • Collecting 2007 and 2008 data from hospitals together • Other states

14. DSHfunctional • 2010 DSH • Distribution originally to conform to DSH Rule guidelines • MCO netted to cost • New uninsured definition • Have created large variances from last year

15. DSHfunctional • 2010 DSH Reviews • No SCHA Audit • SCDHHS Managed care review delayed for additional data requests • Remove zero-paid claims • Exclude Health Connection Kids (SCHIP MCO claims) • Exclude Medical Health Network (MHN) claims • Remove lump-sum adjustments • Plans to review remaining large variances

16. DSHfunctional • 2010 DSH Reviews • Variances in uninsured UPL submissions $30m in charges, $10m in cost (+7.8 to -4.2) • Only reviewing increases • 56 requests • IP over $500k • OP over $500k • Newly qualified hospitals

17. Don’t Shoot The Messenger Presented by: Barney Osborne, SCHA

18. DSHfunctional Last minute revisions • DMH shortfall due to new uninsured definition • Primarily exhausted benefits due to long stays • Hospital ER impact • Revert to 2009 uninsured • Submit “justifiable denials” • Exhausted benefits and pre-existing conditions • Can’t include denials due to lack or precerts or billing errors • Can’t include untimely filing denials • Still settle Medicaid MCOs to cost but dual eligibles have been removed from the calculation

19. Medicaid Budget

20. Medicaid Budget • 2010 rates saved by ARRA extension • 2011 Budget • Potential up to 20% rate decreases • no more stimulus • No progress at legislative level

21. Captive Audience

22. This and That • Medicare charity care audit denials • JAR and Annual Hospital Financial Data Report • Due March 31, 2010 • Need volunteers for Report Task Force • Hospital input on Worker’s Comp professional reimbursement • Free Value Based Purchasing financial and tracking worksheets and training available

23. Healthcare Reform

24. SOUTH CAROLINA HOSPITAL ASSOCIATION • Preparing Medicare impact analysis • Free PowerPoint Presentations • Hospital staff and board • Community • Train the trainer sessions • Board and staff presentations as available • Contact Lara Hewitt 803.744.3518 Health Care Reform:How Will it Change the Delivery System?

25. Questions Barney Osborne bosborne@scha.org 803.744.3544